Medication Administration Education for Unlicensed ...

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Medication Administration Education for Unlicensed Assistive Medication Administration Education for Unlicensed Assistive

Personnel in a Residential School Environment Personnel in a Residential School Environment

Laura Nickerson Regis University

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Running head: MEDICATION ADMINISTRATION FOR UAP

Medication Administration Education for Unlicensed Assistive Personnel in a Residential School

Environment

Laura Nickerson

Submitted as Partial Fulfillment for the Doctor of Nursing Practice Degree

Regis University

May 3, 2018

MEDICATION ADMINISTRATION FOR UAP

i

Abstract

Nurse supervised unlicensed assistive personnel (UAP) medication administration is a frequently

completed health related activity in the school environment (National Association of School

Nurses [NASN], 2017). Students face potential adverse outcomes impacting the school

experience from medication errors (Clay, Farris, McCarthy, Kelly, & Howarth, 2008). School

nurse supervised and directed training for UAP is essential to ensure the mitigation of risk in this

vulnerable population. UAPs themselves have been noted to be uncomfortable with the task and

expressed a lack of understanding of policy and procedures (Canham et al., 2007; Price, Dake,

Murnan, & Telljohann, 2003). It is the role and responsibility of the professional school nurse to

provide oversight, supervision and training of UAP and ensure safe medication delivery to

students (State of Maine, Department of Education [DOE], 2017). The discussed project is an

online medication administration module, which streamlined the staff education process in a

small residential school. The project findings demonstrated increased knowledge and comfort

level after the training intervention supporting ongoing education of UAP in this setting.

Key words: DNP project, unlicensed assistive personnel, medication administration, residential

school


ii

Copyright

Copyright © 2018 Laura Nickerson. All rights reserved. No part of this work may be

reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,

mechanical, photocopying, recording or otherwise, without the author’s prior written permission.


iii

Executive Summary Title: Medication administration education for UAP in a residential school environment

Problem

Medication administration, “is one of the most common health-related activities performed” (NASN, 2017, para. 4) in the school environment, and often involves the use of unlicensed assistive personnel (UAP). The clinical problem was inconsistent delivery of medications in the residential secondary school environment, related to unlicensed assistive personnel.

Purpose This project was intended to serve as a quality improvement endeavor to educate UAPs through online learning modules in medication administration best practices and safety.

Goal The primary goal was to maintain the health and safety of students. The outcomes directly related to nurse training and education of UAP. This educational intervention was structured to provide an easily assessable, convenient method of increasing confidence level and knowledge in medication administration.

Plan This study was quantitative in nature, and compared a change after an educational intervention. Impact was measured by a pre/post survey for UAP’s completing online education based on the School Health Manual Guidelines for Medication Administration (State of Maine, DOE, 2017).

Findings Analysis demonstrated a statistically significant change in UAP confidence and knowledge after the educational intervention, with 86% of eligible UAP participating. A secondary finding in the pre survey was a higher level of knowledge in those that reported having had training at this specific facility in past, regardless of experience or position. This lends support for ongoing and regular education for unlicensed staff regardless of background.


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Table of Contents

I. Preliminary Pages

A. Abstract i

B. Copyright Page ii

C. Executive Summary iv

D. Table of Contents v

E. List of Tables vi

F. List of Figures vii

G. List of Appendices viii

II. Problem Recognition and Definition 1

A. Statement of Problem 1

B. PICO Statement 2 C. Significance, Scope and Rational 3 D. Foundational Theory 4

III. Review of Evidence 6 A. Literature Selection and Scope of Evidence 6 B. Guidelines 7

C. Medications in the Academic Environment 8

D. Family Experiences 10

E. Responsibility of Medication Administration 10

III. Project Plan and Evaluation 11

A. Strengths, Weaknesses, Opportunities and Threats 11

B. Driving and Restraining Forces 13


v

C. Need, Resources and Sustainability 14

D. Feasibility, Risks, and Unintended Consequences 16

E. Stakeholder and Project Team 16

F. Cost-benefit Analysis 17

G. Mission, Vision and Goals 18

H. Process and Outcomes 18

I. Logic Model 19

J. Population and Sampling 21

K. Protection of Human Subjects 22

L. Tool 23

III. Project Findings and Results 25 A. Objective One 25 B. Objective Two 27

C. Objective Three 30 IV. Limitations, Recommendations and Implications for Change 31

A. Limitations 31

B. Recommendations 31

C. Implications for Change 32

V. Conclusion 33

VII. References 34

VIII. Appendices 38


vi

List of Tables

I. Project Resources 15 II. Cronbach’s Alpha 25


vii

List of Figures

I. Conceptual Model 21

II. Training History 26

III. Medication Administration as a Job Responsibility 26

VI. Medication Error History Pretest 28

V. Medication Error History Posttest 29

VI. Spearman’s Rho Test of Confidence and Preparedness 31


viii

List of Appendices

A. Systematic Review of the Literature 38

B. IRB Approval 54

C. Copy of Letter of Approval from Organization 55

D. Participant Information Sheet 56

E. Data Dictionary, Survey Questions & Coding 57 F. Samples Statistics 59 G. One Way ANOVA Questions 2, 3, 4 and 5 60

H. Wilcoxon Signed Ranks Tests 64

I. Citi Certificate 65

1

Medication Administration Education for Unlicensed Assistive Personnel in a Residential

School Environment

Nurse supervised unlicensed assistive personnel (UAP) medication administration is a

frequently completed health related activity in the school environment (National Association of

School Nurses [NASN], 2017). Students face potential adverse outcomes impacting the school

experience from medication errors (Clay, Farris, McCarthy, Kelly, & Howarth, 2008). School

nurse supervised and directed training for UAP is essential to ensure the mitigation of risk in this

vulnerable population. UAPs themselves have been noted to be uncomfortable with the task and

expressed a lack of understanding of policy and procedures (Canham et al., 2007; Price, Dake,

Murnan, & Telljohann, 2003). It is the role and responsibility of the professional school nurse to

provide oversight, supervision and training of UAP and ensure safe medication delivery to

students (State of Maine, Department of Education [DOE], 2017). The following discussed

project is an online medication administration module, which streamlined the staff education

process in a small residential school. The project findings demonstrated increased knowledge

and comfort level after the training intervention supporting ongoing education of UAP in this

setting.

Problem Recognition/Definition

Statement of Problem

Medication administration in the school environment, “is one of the most common

health-related activities performed” (NASN, 2017, para. 4), and often involves the use of

unlicensed assistive personnel (UAP). It is the role and responsibility of the professional school

nurse to provide oversight and supervision of UAP and ensure safe and effective medication

delivery to students (State of Maine, Department of Education [DOE], 2017). In the residential

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environment, medications cannot be deferred to a caregiver after hours, and students may receive

scheduled or as needed medications from a nurse or UAP during the school day, in the dorm

environment or while off campus on school-sponsored trips. The clinical problem was

inconsistent delivery of medications in the residential secondary school environment, related to

administration by unlicensed assistive personnel.

PICO Statement

The PICO question under consideration was: will instituting a formal online, module-

based training program on medication administration safety for unlicensed assistive personnel

(UAP) in a residential school increase UAP’s confidence in, and knowledge of, medication

administration. The population was unlicensed assistive personal (UAP), consisting of any

faculty and staff that may potentially administer medications in the 2017-2018 academic year.

The intervention was a self-paced online module on medication administration procedures and

safety, specific to the facility. There was no comparative as there was no standard medication

administration education in place. After the project it was anticipated UAP should describe an

improved confidence in, and knowledge of, medication administration process as evidenced by

an anonymous pre and post intervention survey.

Historically, there was no consistent or structured yearly training program in place for

staff in this facility, though brief education was offered at orientation or individually as needed

by nurses. The state guidelines for schools noted that a training program must be implemented

yearly if UAP’s are to administer medications (State of Maine DOE, 2017). In this facility,

nurses noted medication logs were left unsigned and students regularly missed doses of routine

medications. The UAP were anecdotally noted by nursing staff to be uncomfortable with the

task, and medication errors went unrecognized.

3

This practice problem was relevant to Doctorate of Nursing Practice (DNP) as a multi-

layered issue involving delegation, supervision and education by the registered professional

nurse, or as it is more commonly termed, the school nurse. It was also one that the literature

describes as a specialty-wide issue that is often problematic in non-healthcare environments,

where nurses are supervised by administrators (NASN, 2014). It fit well with the recommended

DNP focus, “on practice that is innovative and evidence-based, reflecting the application of

credible research findings” (AACN, 2006 p. 4). A system-wide protocol needed to be

established that reached beyond nursing and the school health center to involve other staff, to

make effective change in the facility’s medication delivery system that required full

collaboration across the facility.

Significance, Scope and Rationale

The project needed to involve the health team, administration, faculty, staff, and coaches

to be an effective intervention. It was small-scale in a very specific practice setting, with a core

goal of enhancing student safety. The risk of potential adverse outcomes secondary to

medication errors was high if the status quo was maintained. Safe delivery of medications in the

academic environment has been identified as a common concern across schools and is an issue in

schools nationwide (American Association of Pediatrics [AAP], 2009; Clay, et al., 2008; Gordon

& Barry, 2009; NASN, 2017). Regular and structured UAP training has been identified as best

practice by multiple guiding organizations (AAP, 2009; NASN, 2017; State of Maine DOE,

2017). This intervention would also provide clear evidence to demonstrate the organizational

commitment to Maine State Guidelines for schools (State of Maine DOE, 2017).

4

Foundational Theory

There are several advanced practice nursing outcome measures addressed by the project;

health care policy, advocacy in health care, inter-professional collaboration, clinical prevention

and population health (Zaccagnini & White, 2017). All of these outcomes link to the National

Association of School Nurses (NASN), Framework for 21st Century School Nursing Practice,

which provides, “student centered nursing care”, (NASN, 2016, para 1) and emphasizes the use

of evidence-based care. This framework was used to provide structure and support for the quality

improvement project and helped to enhance focus for a school based intervention.

This was an integration initiative, as per Boyer’s Model of Scholarship (Nilbert, n.d.). It

involves collaboration with other nurses, administration of the school and UAPs, all of which

were focused on the core of student safety. This was in keeping with the NASN Frameworks,

which acknowledges several key principles that are relevant, including care coordination,

leadership, and quality improvement (NASN, 2016). The ultimate goal was to have a program

the nursing staff coordinate and supervise to support and educate the UAP in safe medication

delivery. The nurse needed to be a leader and collaborate within the organization’s system for

quality improvement to enhance student safety.

Culture of the facility was a major consideration in selection of secondary foundational

theory. The facility’s routines and habits were well established and the project would be

requiring a system wide culture change. Organizational Culture Theory, as developed by Schein

(1990), a non-nursing grand theory was selected to address this issue and is a model that can

assist in overall culture change in an organization. Schein (1990) developed a visual

representation of the model with assumptions at the core, followed by espoused values and all

surrounded by artifacts and symbols. Artifacts are the most exterior layer and are visible parts of

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an organization, such as an emblem for business. The middle layer is espoused values, which are

the rules and standards of the business. The innermost layer is the assumptions of the

organization and conduct not always recognized by individuals (Schein, 1990).

In these layers of the organization, the outer most is the easiest to alter, and as the layers

proceed to the core, or the assumptions, they become more difficult to adapt and change. For

example, it is easier to change the design of a company’s product, the artifacts, than to change a

behavior of its employees, the assumptions (Schein, 1990). This is relevant to the project as

previous training on medication safety has been sporadic for returning staff and not well defined.

Introducing a routine of yearly training, and an increased awareness of medication safety will

require staff to adjust ineffective routines that have been historically well established. Changing

the packaging of the mediations would be a relatively easy change, representing a change of the

artifacts. However, changing the assumptions, such as the workflow of UAP medication delivery

and shifting the focus to medication safety, would be much more difficult.

Langan-Fox and Tan (1997) note there are multiple documents that explore culture

change in an organization, often with differing opinions on what organizational culture is. The

authors note that Schein’s model is more comprehensive and offers a framework for evaluation

of a culture (Langan-Fox & Tan, 1997). This model can be easily fit to various settings and a

residential school with long-standing traditions, or assumptions, fits with the model well.

This theory was also chosen for its relevance because medication administration in the

independent school environment must be a collective effort, not limited to nursing staff.

Successful and safe medication administration relies on effective communication, education, and

training and strong system wide commitment. This theory lends support to the idea that effective

instruction may make the layers of the culture more congruent and therefore enhance the safety

6

and consistency of medication administration to the students. School nurses are essential in the

organizational structure to ensure a, “culture of safety” that can reduce errors (NASN, 2017,

para. 7). All efforts to improve the process must be generated and directed by the professional

school nurse to enact meaningful and evidenced-based practice change.

As this was also an adult education project, a learning theory was needed. Knowles

Theory of Andragogy (Knowles, 1980) was selected as a fit for the intervention. The five core

concepts, self-concept, the experience an adult learner brings to learning, their readiness to learn,

their orientation to learn and also their motivation to learn (Knowles, 1980) can be used to frame

the education. The first concept that was incorporated into the educational intervention was that

it was self-directed. It was offered online at the UAP’s own pace and given a window of almost

two months to complete. Encouragement to complete within the first two weeks of school and

prior to any dorm duty or off campus trips was highlighted. Secondly, it was goal oriented, with

student safety emphasized repeatedly. The intervention was also relevant to experience as many

of UAP had been within the residential school environment for some time, and the learning

acknowledged this familiarity. Finally, the education was practical and anchored to real world as

this was a duty that multiple staff have been required to do on a frequent basis.

Review of Evidence

Literature Selection and Scope of Evidence

In conducting a literature review on this practice problem, both the Cumulative Index to

Nursing and Allied Health Literature (CINAHL) and Medline databases were used. The terms

“school”, “medication administration” and “unlicensed assistive personnel” were searched. The

search resulted in 379 articles when all three terms were used, with an increase when only two of

the search terms were utilized. A total of 13 articles were selected with particular attention paid

7

to the journals specific to the school-nursing specialty and pediatric focus (see Appendix A).

There were four Level VII (Thompson, 2011) articles that included descriptions of implemented

programs, discussion of medication administration safety. Eight Level VI (Thompson, 2011)

articles disusing single studies, survey of nurses, administrators and UAP on topic of medication

administration were used. One Level III (Thompson, 2011) article, a quasi-experimental design

after educational intervention was also included. The relevant literature can be found organized

in Appendix A. Several guiding agency documents were also utilized, including the State of

Maine – School Health Manual (State of Maine DOE, 2017), the position statement from the

NASN on medication administration (NASN, 2017) and the policy statements from American

Association of Pediatrics (2009; 2016).

One theme that quickly emerged was that all stakeholders, including school nurses,

administration, staff and parents, had concern for safe medication administration for students

(AAP, 2009, Clay, et al, 2008; Gordon & Barry, 2009; Gursky & Ryser, 2007; NASN, 2017).

All stakeholders wanted focus to be on student safety through process. It was generally

recognized that potentiating student health also potentiates student success in the academic

environment (AAP, 2009).

Guidelines

There were several guiding agencies and organizations that discuss the need for safe

medication practices. The Committee on School Health noted that protocols to prevent

medication errors and staff training were essential in the administration of medication in a school

setting (AAP, 2009). They recognized the need for delegation, but stressed the importance and

the central role of the professional school nurse in safe medication administration (AAP, 2009).

The Maine State Guidelines noted that a training program to ensure safety, guided by the school

8

nurse, must be implemented if UAP’s are to administer any medications in this environment

(State of Maine, DOE, 2017). The guidelines offered suggestions for instruction, but did not

require a specific type or format for the education. It was noted the professional school nurses’

responsibility to understand state guidelines and nurse practice acts in the formation of any

policy or procedure for medication administration (NASN, 2017).

The National Association of School Nurses Medication Administration in Schools:

Position Statement (2017) is one of the school nurse’s guiding documents in providing

evidenced-based care related to medication administration. This document specifically addressed

the need for UAP training and education to reduce potential errors. As the expert, the school

nurse should be the leader in efforts in procedural development, training of UAPs, and

supervision of the process to ensure student safety (NASN, 2017). There must also be frequent

and ongoing evaluation of processes by the school nurse to ensure quality and safety (AAP,

2009; NASN 2017).

Medications in the Academic Environment

Historically, school nurses were placed to help decrease absenteeism, but that role has

evolved to a broader practice, including medication administration and involves a team both in

the school and in the community (AAP, 2016). The process and safety of medication

administration in the academic setting is not well defined, and there was extensive discussion of

potential for errors within the literature when using UAPs (Canham, et al., 2007; Gordon, &

Barry, 2009; McCarthy, Kelly, & Reed, 2000; Wilt & Foley, 2011). Missed does were listed as

the most common error in several discussions (Clay, et al., 2008; Canham, et al., 2007; Kelly,

McCarthy, & Mordhorst, 2003; McCarthy, et al., 2000; Richmond, 2011) and have been

anecdotally noted in this project setting though no formal tracking method is in place.

9

Despite the increase in students with medical needs, there is limited data collection

happening in schools overall (Richmond, 2011; Robert Wood Johnson Foundation, 2010). No

data could be found specific to UAP medication administration in residential schools. There was

a frequent call to increase research on the topic specific to schools (Bergen, 2011; Clay et al.,

2008; Gordon & Barry, 2009; Litarowsky, Murphy, & Canham, 2004; Richmond, 2011; Wilt &

Foley, 2011). Furthermore, UAPs themselves were noted to be uncomfortable with the task and

expressed a lack of understanding of policy and procedures (Canham et al., 2007; Price, et al.,

2003).

Litarowsky, Murphy, and Canham (2004) concluded that a training intervention for

UAPs can demonstrably increase knowledge and confidence in a health related topic. Though

this was a small-scale study, specifically addressing the treatment of anaphylaxis, the positive

impact suggested that further study on UAP knowledge and confidence after education may be

valuable. This study parallels well with the proposed small scale UAP education project.

A retrospective study of medication administration in eight public schools in California

reinforced the need for yearly continuing education of unlicensed assistive personnel (UAP) and

the nurses’ responsibility for ongoing year round assessment of process (Canham, et al., 2007).

The authors noted the discomfort of UAPs administering medications and clearly define the

requirements of a medication administration policy. Medication administration in the school

setting can augment academic success and general health and is an essential service, even when

there is not a professional nurse present (NASN, 2017), but care must be taken to mitigate risk of

error. Medication errors increase chances of adverse outcomes and UAPs administering

medication in school is a, “safety issue that can potentially lead to litigation” (Canham, et al.,

2007, p. 27). The risk to students if untrained UAP are used can include diminished health and

10

academic outcomes, and represent liability for the organization and individual school nurse

(AAP, 2009).

Family Experiences

From the family perspective, parents and students seen in an urban hospital were

surveyed on the medication experience in schools (Clay, et al., 2008). The authors found a high

incidence of medication errors that could impact a student’s school experience, such as missed

doses of medications prescribed to assist focus. There are adverse outcomes associated in the

school age child when medication routines are disrupted (AAP, 2009; Clay et al., 2008). This

supports that medication delivery is particularly problematic in the school setting and

organizational teamwork is imperative in a successful protocol. References specific to the

residential setting were noted to be limited in the literature. School nursing is an isolated

specialty, and residential school nursing an even smaller subset.

Responsibility of Medication Administration

A secondary point that appeared was the confusion among school administrators on who

is responsible for medication management; with the administration feeling they were ultimately

responsible and not the nurse (Farris, McCarthy, Kelly, & Gross, 2003). This is untrue and the

need for nurses and administrators to understand their Nurse State Practice Act was repeated

(Ficca, & Welk, 2006; Kelly, McCarthy, & Mordhorst, 2003; Wilt & Foley, 2011). It is

acknowledged that professional school nurses must be in control of delegation, coordination and

oversight and offer expertise in this health related function (Farris, McCarthy, Kelly, & Gross,

2003; Ficca, & Welk, 2006; Gordon & Barry, 2009; Kelly, et al., 2003; McCarthy, et al., 2000;

NASN, 2017; Price, et al., 2003; Wilt & Foley, 2011).

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Project Plan and Evaluation

Strengths, Weaknesses, Opportunities and Threats

In looking at the project plan and evaluation, the intervention had several strengthening

factors. Overall staff dedication to student success is high in this environment. Faculty and staff

function in locus parentis, meaning in the place of the parent (Collins Dictionary of Law, 2017)

in the residential environment, and staff take this position very seriously. Each student is

assigned a faculty advisor and the relationship often becomes close, with staff willingly invested

in each student. This dedication extends to the administration as well. Many are alumni or have

had their children attend the school and have a personal investment in success. There is a deep

commitment organizationally to the school and the students.

Another strength was the strong and experienced nursing staff in place and available

around the clock to provide ongoing support. There were three full time nurses available to UAP

for questions. Additionally, the Associate Head of School, and supervising administrator of the

health center, was a nurse and recognized the need for safety training. Nursing was already

afforded a strong autonomy and respect in the organizational culture and administration was

receptive to concerns.

This particular school caters to a very healthy student population, secondary to a strong

competitive winter sports program, with limited medical needs. Unlike public schools,

independent schools have selective admissions can refuse or restrict a student with complex

needs due to the nature of residential school. This limits the medications that must be

administered by UAP.

There was already an online platform in place in the school and supportive informational

technology personnel. As the setting was a school there was a cultural awareness of the value of

12

education and training and overall interest in the intervention. The platform has been used by

faculty to instruct and was familiar to them.

In discussion of weaknesses, demand on UAP time was an issue. This training

represented a block of time when faculty and staff least could afford to spare it, at the start of the

school year. Requiring additional training time for a new process was a consideration. Because

of the time commitment, UAP and administration needed to buy-in to the project and its value.

Other weaknesses included very few of the UAPs had any medical background, though

several coaches held various first aid certifications. There was a general lack of knowledge about

safety and medications, which can create an atmosphere where this aspect of health is not a

priority. Policy and procedures on medication administration had been housed in the Health

Center and not readily available to staff to review. This was also compounded by typical staff

turnover and regular intake of winter coaching staff.

Delivery itself was complicated as well. There were students needing medications in all

variety of settings, on and off campus. The majority of medications were distributed in the

Health Center during day hours and provided by nursing, but students received medications in

the dormitories or while off campus on trips. Due to the active winter sports program, students

traveled extensively with coaching staff and often left with little notice. Although the healthy

student population was a strength, there were still medications with some complexity given. For

example, during the time of the project intervention, several students had multiple “as needed”

medications available in the dorms’ medication lock boxes for after-hours administration.

In the medical and nursing literature, there has been an increased awareness of the impact

to medication errors. Overall, health care is recognizing the need for solid systems and

procedures to decrease risk. Although there is limited data on schools specifically, there is

13

tremendous data in the health care world. This represented an opportunity to extend this

awareness to the school environment. Concurrently, the administration of the institution had

recently become aware of a variety of school safety initiatives in the industry that created an

openness to change allowing for an enhanced opportunity.

There was no set standard for education for unlicensed assistive personal (UAP). There

were multiple materials available and even a training guide developed by the state, but it had

little relevance in this setting. There was very little guidance available specific to the needs of the

residential environment. All materials and training needed to be adapted, and represented an

outside negative influence. The challenges faced in this specific setting were very different from

public, day schools where there may have been well established training. As well, state law was

variable from state to state and differs from public to independent school.

Driving and Restraining Forces

The driving forces behind the project primarily centered on student safety and were in

keeping with the structural frameworks provided by the National Association of School Nurses,

Framework for 21st Century School Nursing Practice (NASN, 2016). They evolved from Health

Center staff concerns about recurrent medication errors including missed, incorrect or uncharted

medication doses. The school was student focused, as evidenced by their mission (Gould

Academy, 2017), which spoke to a safety project such as this. Additionally, as an educational

facility, staff valued instructional concepts and saw worth in education generally, just by nature

of the culture.

Some of the restraining forces were related to the organizational resistance to change. As

is highlighted in Organizational Culture Theory (Schein, 1990), this type of change can be

difficult to effect. The project was challenging well-established patterns and values. With

14

limited health care exposure, the staff may not be aware of the dangers inherent in medication

administration. The student population was also overall very healthy, and staff rarely saw a

complex medical issue. Scheduling the training was also a potential restraining force. Staff are

already expected to work long hours due to the residential nature of the school and finding time

to fit in one more training may have been difficult.

Need, Resources and Sustainability

The need for the project was demonstrated through the literature review noting this being

a national issue experienced in other schools (Canham, et al., 2007; Gordon, & Barry, 2009;

McCarthy, Kelly, & Reed, 2000; Wilt & Foley, 2011) and not unique to the residential

environment. The literature review also demonstrated UAP education is considered best practice

and in keeping with safety standards (AAP, 2009; State of Maine, DOE, 2017; NASN 2017).

Prior to implementation, the medication errors nursing staff were noting and general lack of

knowledge, provided impetus for change. Finally, there was the potential for legal ramifications.

If the facility was not adhering to best practice this left the school, nurses and staff at risk for

litigation (Canham, et al., 2007).

Fortunately, the resources for this specific project were already in place representing a

limited financial commitment to implement the project. The online learning system was already

in use at the school, the staff were already familiar with navigation and there were no associated

extra financial costs with its use. A course platform was granted to the Health Center and the

Informational Technology department acted as a resource. The survey was collected using the

cloud-based site, SurveyMonkeyTM (2017) and only basic features were accessed, used free of

charge. The primary cost to this specific project was nurse time and time for UAPs to complete

the training.

15

If the project were to be repeated, the financial costs would need to be factored (see

Table 1). An online platform would need to be in place to make the project viable. This is

realistic as most schools now use online learning as a component of education. Depending on the

platform, there may be an associated cost to extending use to the education. SurveyMonkeyTM

fees would need to be factored if more extensive statistical features were used. If not, a software

package such as SPSS would need to be purchased. Again the primary costs, somewhat hidden,

would be staff time. It takes nursing time to create, initiate and maintain and staff time to

complete. This cost would vary depending on the number of staff needing training.

Table 1. Project Resources

Sustainability of this project in this particular facility is generally favorable. As there are

limited financial resources required, it has a strong selling point to administration. Nursing staff

are salaried and already in place and can provide updates and maintenance as needed. UAP staff

time remains the primary drain. However, with the use of the online platform this allows the staff

to complete at a time most convenient to them.

At the time of this writing, the Health Center online page continues to be active on the

platform with support from administration. After the project completed, the survey links specific

16

to the project were removed and the education was kept in place for any staff incoming over the

winter term, such as winter ski coaches. The Health Center expectation is to develop a

streamlined training for returning staff for the following academic year that would meet the

public school standards of yearly education. It would also help keep staff aware of any policy

changes and adapt content as new issues arise. At the time of this writing a second module has

been added to allow staff to access state mandated training. This allows the staff to log in at their

convenience and work at their own pace, as opposed to lengthy meetings.

Feasibility, Risks, and Unintended Consequences

For risks or unintended consequences there was a possibly of educational fatigue. With

building modules there was concern that staff would simply get tired and perhaps not complete

appropriately. During the course of this project this was not an issue noted, but may be of

concern in future if use of this delivery system continues. One risk not anticipated and heard

anecdotally from staff after implementation, was that they were stressed by the education.

Several UAP noted that they had never worried about the process before, but now nervous about

it. One staff member stated to the author, “I was happier ignorant”. The debate might be if this is

a true unintended consequence or a healthy fear. Nervousness about a high-risk activity might

denote that staff are taking the responsibly seriously. As long as they are not paralyzed by the

fear, or avoid medications because of it, it may actually be an unintended benefit.

Stakeholders and Project Team

The stakeholders related to this project were all invested in student safety, with the main

stakeholder the student and their families themselves. Certainly, the health center staff, the

nurses, who were primarily responsible for medication safety in the school environment were

also key stakeholders. Beyond this, the schools primary mission was student success, of which

17

student safety was essential. The administration and Board of Trustees should expect best

practice in all services including medication administration. The UAP themselves were directly

involved in the task and were required to be active participants in the educational offering.

Due to the limited scope and small size of the project, the team was essentially limited to

one member, the Director of Health Services and coordinator of the initiative. However, key

support was provided by Health Center nurses, the Associate Head of School, who was the direct

supervisor of the Health Center staff, and also by the Director of Technology. The author’s

university chair and mentor was involved in project planning and refinement. Human resources

and their division head, the Chief Financial Officer, also had to green light the project as it

involved staff training.

Cost-benefit Analysis

The risk of potential adverse outcomes if the status quo was maintained was very high.

There is a higher risk of medication errors when UAP’s are not trained and educated in safety

procedures (NASN, 2017). Not implementing change on this safety related issue leaves the

students and organization vulnerable to adverse outcomes. Prior to implementation, there had

been several medication errors with distinct and noticeable impacts on student health. There were

no tracking systems in place in the organization to note medication errors, so the extent of the

clinical issues in this specific facility were not well defined. This represented the primary reason

this topic was chosen for quality improvement. The risks to the students, the litigations risks to

the school and the professional risks all played a key component in importance.

Costs of medication errors are well defined in acute care, but very little data on error rates

and cost exist for the school setting (IOM, 2007). Medication errors are at higher risk when

UAP’s are not trained and educated in safety procedures (NASN, 2017). With the understanding

18

that health impacts academic success (AAP, 2009), and the ability of a student to remain

effectively in school, the stakes are high. The National Association of School Nurses notes that

students must be, “healthy, safe and ready to learn” (NASN, 2016, p.218).

One of the selling points to the facility’s administration was the risk analysis from a legal

standpoint. If there is non-adherence to the best practice by regularly training UAP in this high-

risk task, the school is vulnerable for fault. This was a priority concern for the nursing staff on a

professional level and as supervisors of the process, a risk to licensure.

Mission, Vision and Goals

This project intended to serve as a quality improvement endeavor to educate UAPs

through online learning modules in medication administration best practices. The primary goal

was to maintain the health and safety of students in the residential environment.

The mission of the school centers on the student and preparation for an excellence driven,

ethical life (Gould Academy, 2017). This student-centered mission was congruent with the

mission of the project and keeps the student well-being at the core, consistent with the project

structural support, Framework for 21st Century School Nursing Practice (NASN, 2016).

Process and Outcomes

In the school-nursing specialty, the typical nurse-sensitive outcomes are unlike acute

care. School nursing has been noted to have a shortage of identified outcomes that demonstrate

quality care (Bergren, 2011). As a profession, school nurses may be unable to advocate for their

value without pointing to indicators that measure and reflect their impact. This subspecialty

functions within a non-medical environment, and faces a deep lack of understanding. Expertise

of the nurse in developing policy and ensuring safety in student medication management is

essential in school environments (NASN, 2017).

19

The outcomes for the project were directly related to education of unlicensed assistive

personnel (UAP). It has been noted with UAPs in a public school setting, a common theme of

discomfort with giving medications echoed throughout the literature (Canham, et al., 2007; Price,

et al., 2003). This educational intervention would ideally increase confidence level and

knowledge of medication administration, and therefore increase student safety. The organization

sensitive outcomes to achieve that goal were:

1. 100% of eligible UAP will complete training by 10/15/2017.

2. UAP will demonstrate an increased knowledge of medication administration as

evidenced by pre/post survey scores.

3. UAP will report an increased confidence with medication administration as evidenced

by self-reported pre/post survey scores.

Logic Model

The conceptual model acknowledged (see Figure 1) administration was needed as input

to support the implementation of the project and the need for staff training. UAPs participation

were required inputs, as they were engaged in the training. The Canvas online learning platform

was used to deliver the education, as well as the cloud-based data collection tool, Survey

Monkey for data collection.

A constraint would be the culture of the organization. This shift to the online platform,

and extra demand on the UAP time might have been seen negatively. This may have adversely

impact the stakeholder buy-in for the project. Administrative stakeholders needed to be

informed of potential adverse outcomes of continued UAP unfamiliarity of best practice and

safety standards. Securing buy-in by emphasizing safety and potential risk was helpful

combating this.

20

The intervention was the online learning for any UAP who may be required to administer

medications. The training was based on the State of Maine School Health Manual Guidelines for

Medication Administration (2005). The content was adapted to the setting as the predominant

medication route was orally administered and a UAP is rarely, if ever, asked to administer any

other medications.

The other adaption was acknowledging and emphasizing the round-the-clock availability

of the nursing staff. Those participating were asked to complete a pre and post survey measuring

knowledge of medication administration safety and confidence in procedure. The outputs then

measured increased confidence level of the UAP and an increase in knowledge.

The short-term goals were for all UAP to complete the training with the hypothesized

increased knowledge and confidence. Long term, the UAP will be divided each year into cohorts,

where returning staff can complete a streamlined and condensed training and new incoming staff

will receive the full education. As noted, there are other educational offerings focused on health

center topics, such as concussion care, that could be offered in this format and stand to benefit

the health and wellness of students.

Overall, the assumed impact of this project was increase in UAP competency in

medication delivery. Utilizing the online delivery system in a self-paced manner could also

increase the efficiency of the UAP yearly orientation. Staff could participate at any time,

regardless of scheduling. Any staff that are hired though the school year could easily access the

self-paced module which would assist in their orientation without repeated drain on nursing time.

21

Figure 1. Conceptual Model

Population and Sampling

The environment of the project was a private, non-profit, residential boarding school. In

this non-clinical setting, there were approximately 260 students, the majority of whom board, as

opposed to day students. Faculty and coaches were the primary UAPs involved with medication

delivery in the dorms, off campus trips and when a nurse was unavailable. There were a few

other individuals, such as business office staff, which were assigned dorm duties and were

included in this convenience sample. The number of potential participants was tallied at 71. This

was a quasi-experimental, one group pretest and posttest design, with no randomization and no

control group. While not the best of methods, it was the most reasonable for this setting, and

assigning a control group would have been inappropriate. As this was a small sample size, in a

relatively specialized area, this was the most reasonable approach.

22

Protection of Human Subjects

The school had no formal policy or procedure for research and IRB approval, and was

granted exempt status from Regis University (see Appendix B). Approval from the Head of

School, Associate Head of School and the Chief Financial Officer, who supervises Human

Resources, was also sought. None of the three were involved in the survey or education, as they

do not provide meds to students. The Head of School gave official signed permission (see

Appendix C). The project was introduced to the population at the start of the school year 2017.

Emphasis was placed on the ease and flexibility of both the timing and training completion in

effort to encourage participation.

As the project was not looking directly at the students, nor their educational practices,

there were no special criteria in relation to the school environment (US Department of Health

and Human Services, Office for Human Research Protections, 2017). Participation was voluntary

and the participants could withdrawal at any time. There was no identifying information

collected, nor any protected health information. Participants were asked for a code word for both

the pre and post survey to give the ability to match answers if desired during data analysis.

SurveyMonkeyTM, an online survey tool, was used to collect the data. Participants were reassured

there was no connection to the survey and their employment. The project involved minimal risk

for the participants, consisting of possible discomfort with perceived testing. The participants

were all the age of majority and the investigator is not considered a UAP supervisor. A letter

preceded the survey and explained that participation implies consent, (see Appendix D), and the

survey was presented as totally voluntary and all replies confidential. Also, when the project was

introduced, participants were encouraged to see nursing staff with any questions that might arise,

either in person or via email. Approximately ten staff did contact nursing after with content and

23

follow up questions.

Tool

This project included a pre and post survey for the unlicensed assistive personnel (UAP)

completing the education (see Appendix E). The data collection of the survey looked

specifically at the PICO question of confidence and knowledge. The survey was completed

through SurveyMonkeyTM from embedded links in the learning module to encourage

participation. The organization and faculty often use SurveyMonkeyTM for informal data

collection, and were generally familiar with its use, which was a benefit

This study was quantitative in nature, comparing a change after an intervention. The

survey contained the same knowledge and confidence questions both pre and post education. A

10 point scale was used to assess subjective data such as confidence. Multiple choice and fill in

the blank were used for knowledge. There was one question on creation of a personal code, four

demographic questions, four subjective questions and ten knowledge questions for a total of 19

questions on the pre survey (see Appendix E). The post survey was identical, minus the

demographics questions that were eliminated from the posttest.

Lavin, Slepski and Kasper recommend selecting a subject matter expert that, “ is familiar

with those for whom the project is intended” (2007, para 16). The former State School Nurse

Consultant of Maine, N. Dube, who was also one of the core developers of the Maine State

Guidelines for UAP medication training (personal communication, May 4, 2017) was used as a

resource for the overall project. These guidelines were created by a multidisciplinary group,

including the Maine School Health Advisory Committee (2005) and went through multiple

revisions and review processes to establish content validity (personal communication, N. Dube,

May 4, 2017).

24

Previous surveys in the literature have been used to measure UAP comfort level and these

were used as a guide to format comfort questions. Specifically, Price, et al. (2003), completed a

large-scale survey of UAP and the survey tool included questions that would be relevant in this

setting. That tool was developed using face validity after a literature search, and review by

multiple content area experts (Price et al, 2003). The questions for this project were adapted for

use in the subjective portion with small changes to reflect the environment of a residential

school. Several of the initial research questions were omitted, as they were not relevant to this

practice setting and in a desire to decrease length of survey.

Content questions were directly related to objectives of the education, such as medication

error recognition and safety procedures. These questions were adapted and guided by the state

School Health Manual suggestions for UAP training (State of Maine, DOE, 2017). The content

questions were also reviewed by the project’s subject matter expert, with minor wording changes

incorporated. Overall, the tool for this project was established by a combination of face and

content validity by modeling previous research and use of a content expert.

A pilot run was considered, but discounted, as the target population was small. The

Cronbach Alpha did return as low at 0.448 (see Table 2). There are several possible explanations

for this. It was a newly created tool, taken from a variety of sources and adapted to use in this

specific environment. The tool contained multiple styles of questions and the number of

questions were limited (Tavakol, & Dennick, 2011). All of these can contribute to the low score

and which would need to be addressed prior to recreating the project in future.

25

Table 2. Cronbach’s Alpha

Project Findings and Results

Objective One 100% of Eligible UAP Will Complete Training by 10/15/2017

The first objective was to have all UAP with potential to administer medications in the

organization in the academic year 2017-18 complete online training within six weeks of return to

campus. While this goal was not achieved there was significant participation, with 86% of the

eligible faculty, staff and coaches participating, meeting the threshold of >80% participation.

There were a total of 71 eligible participants, with 66 logging into the training, 61 completing the

pretest and 50 completing the posttest.

As was representative of the population, faculty made up the predominant group logging

into the training.

On the demographics section UAP were asked if they had ever received training at the

facility. Institutionally, over 50% did not receive training or did not remember receiving training,

highlighting the need for a formalized process (Figure 2).

26

Figure 2. Training History

UAP were asked if they believed medication administration was a part of their job (see

Figure 3). A surprising 75% of UAP responded positively, possibly suggesting a willingness to

perform the task.

Figure 3. Medication Administration as a Job Responsibility

27

Objective Two UAP Will Demonstrate an Increased Knowledge of Medication

Administration as Evidenced by Pre/post Survey Scores

At the initiation of the data analysis, a decision was made to not use the participant codes

to match up answers. Firstly, with the small sample size there were 11 pretests that would have

to be discarded in analysis, as they did not complete the posttest. Secondly, when looking at

overall objectives, the individual scores were not relevant. The primary objective was overall

confidence and knowledge and could be captured with mean scores. A t test was used on the

population means as opposed to a paired samples t test where codes would have been utilized.

Answers were coded as correct or incorrect regardless of style of question (see Appendix E).

Overall, UAP knowledge improved after the intervention. P-value showed significance,

and mean values showed positive increases. Four out of ten knowledge questions showed a

statistically significant positive change. Six out of ten showed no statistically significant change,

and out of those, three mean scores were increased and three mean scores decreased (see

Appendix F).

Using a t-test, four out of ten questions showed statistically significant positive increase

(Appendix F);

• Question 10 regarding medication refusal (t = -2.858, p-value = 0.006)

• Question 12 regarding the Five Rights (t = -9.8, p-value = < 0.001)

• Question 16 regarding documentation (t = 5.687, p-value = < 0.001)

• Question 17 also regarding documentation (t = 2.333, p-value = 0.24)

Three of the ten questions showed a mean increase that was not statistically significant

(where p-value was >0.05). Though not statistically significant, the mean scores increased

slightly showing positive change. These questions were;

28

• Question 15 regarding medication refusal (mean pre 20.92, post 20.98)

• Question 18 regarding law (mean pre 20.48, post 20.52)

• Question 19 regarding medication identification (mean pre 20.90, post 20.96)

Finally, three questions showed decrease in mean score. While not statistically significant

the drop in mean scores may suggest the content or the following questions need revision;

• Question 11 medication error (mean pre 20.24, post 20.22)

• Question 13 medication ID (mean pre 20.94, post 20.90)

• Question 14 as needed medications (mean pre 20.78, post 20.70)

No specific statistic was completed on question number nine regarding medication errors.

UAP were asked if they had ever made a medication error. This was more informational and

very site specific and simply included for general information. Raw data only was used. There

was an increase from 8% of respondents stating they had ever made an error on the pre test to

32% in the posttest (see Figure 4 and Figure 5). This correlates with the anecdotal comments

received from several staff that they were unaware of medication errors in general.

Figure 4. Medication Error History Pretest

29

Figure 5. Medication Error History Posttest

In further exploring knowledge, demographics were analyzed for links. As these items

were independent, a one-way analysis of variance (ANOVA) was completed (see Appendix G).

The respondents position at the facility, faculty, coach or staff, showed no statistically significant

correlation to knowledge on pre survey (no p-values < 0.050 for questions 7-19).

The question asking for years of experience in any school setting showed statistically

significant correlation to two knowledge questions (see Appendix G). Question number 17,

which discussed medication documentation (p-value = < 0.001, f – 3.796) and question number

19 regarding medication identification (p- value = 0.003, f -2.734) showed a correlation. With

only two questions demonstrating this link, this suggests years of experience had minimal impact

on initial knowledge.

Respondents gave answers on years of experience in this particular facility (see Appendix

G). The one-way ANOVA showed no statistically significant correlation (no p-values < 0.050

for questions 7-19), suggesting there was no impact of time at employment on knowledge.

Finally, respondents were asked to report if they ever received training at this particular

facility (see Appendix G). This one-way ANOVA analysis showed statistically significant

correlation to three questions. Question number 7, regarding self-reported preparation (p-value =

30

0.041, f = 3.382) question number 9 on medication errors (p-value = 0.038, f = 3.472) and

question number 19 on medication identification (p-value = 0.031, f = 3.684) all had statistically

significant correlations. These findings might suggest that previous training had the most

positive impact on knowledge scores. In looking at all the one-way ANOVA results it might

suggest that that experience had limited impact, but training had a strong positive impact,

supporting routine and regular UAP education.

Objective Three UAP Will Report an Increased Confidence with Medication

Administration as Evidenced by Self Reported Pre/post Survey Scores

The second objective addressed related to UAP self-reported confidence with medication

administration and was asked on both the pretest and posttest. The questions on both confidence

and preparedness were grouped in this category. The Wilcoxon Signed Ranks test was used to

evaluate confidence and preparedness pre and post as a scale was used, and it was ordinal data

(see Appendix H). Both questions demonstrate a statistically significant increase in ratings,

matching the objectives. Specifically, UAP ratings of preparedness demonstrated a statistically

significant increase after the intervention (see Appendix H). UAP ratings of confidence

demonstrated a statistically significant increase after the intervention as well (P-value = < 0.001,

mean pre 6.61, post 8.42).

This objective was further evaluated using a Spearman’s Rho test on the confidence and

preparedness questions to evaluate for a correlation between the two items, preparedness and

confidence (see Figure 6). Spearman’s Rho testing of the questions showed a strong correlation.

If the participant rating was high for one of the items on the pretest, then they would likely rate

the other item high and also true of the posttest (pretest p-value = 0.908, posttest p-value =

0.963). However, there was no cross correlation. For example, if they rated their confidence high

31

in the pretest there was no correlation to preparedness in the posttest (see Figure 6).

Figure 6. Spearman’s Rho Test of Confidence and Preparedness

Limitations, Recommendations and Implications for Change

Limitations

There were several limiting factors for this project. This was a small-scale educational

intervention for a tight-knit employee group that were easy to connect with. The project design

was very site specific, tailored to an independent residential school and would be difficult to

generalize to the public, day school setting. As this was a relatively unique environment, the

training reflected the generally healthy and well student body with limited medications. There

were also geographical limitations as board of nursing and state requirements vary state to state

and may not be relevant elsewhere.

Recommendations

Overall there is a recommendation for further research in keeping with the

recommendations of much of the available published work on the topic of medications and UAP

use in schools. The lack information on medication safety in the school setting leaves a void in

32

the pursuit of evidence-based practice. There is also a distinct lack of information specific to the

unique environment of a residential school. Without evidence to guide practice, the specialty of

independent nurses is forced to interpret and utilize non-specific data.

The project would need revision if there were an attempt to recreate. The education itself

needs refinement and clarification to reflect the needs of a particular facility. Also, in light of the

low Cronbach’s Alpha score, the survey tool would need to be edited to potentially increase

value and specificity of the data obtained. Actions that could increase this score include

expanding the number of questions while limiting the types of questions.

Implications for Change

Potential general implications of the information obtained during this project include

support for regular unlicensed assistive personnel (UAP) education on medication safety. The

results also support the concept that education may have more value than experience in the

setting. As the independent residential school is a unique environment, there is a clear need for

more data to support practice change.

The information obtained may be more useful in the facility itself. The findings support

the continued and regular education of UAP within this setting to potentiate student safety. An

area for further study in this facility might include focus on medication errors. As there is

currently no tracking system, data revealed through careful monitoring might help pinpoint focus

for future education on medication safety. The positive results would also support the use of this

platform for continuing education for UAP on other topics. Since project completion, a learning

module has been added for UAP training on a state topic and two new modules are under

development for launch in the next academic year, all with the full support of the administration.

In looking overall health policy implications, the lack of information available suggests a

33

need to clarify and expand discussion on UAP use and role in the school setting. Clarity on

general health related topics and how the impact an independent or residential school

Conclusion

Nurse supervised UAP medication administration in the school environment is a

frequently completed health related activity. Students face potential adverse outcomes impacting

the school experience from medication errors (Clay et al., 2008). School nurse supervised and

directed training and education for UAP are essential components and are required to ensure the

mitigation of risk in this vulnerable population. This project of an online medication

administration module streamlined the staff educational process in a small residential school. In

this unique environment the training demonstrated a significant positive impact on UAP

knowledge and confidence in medication administration safety.

34

References

American Academy of Pediatrics (AAP), Council on School Health. (2009). Guidelines for the

administration of medication in school (Policy Statement). Pediatrics 124(4), 1244-1252.

American Academy of Pediatrics (AAP). (2016). Role of the school nurse in providing school

health services (Policy Statement). Pediatrics, 137(6), 1-6.

American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral

education for advanced nursing practice. Retrieved from

http://www.aacn.nche.edu/dnp/Essentials.pdf

Bergren, M.D. (2011). Does school nursing matter? NASN School Nurse, March, 72-74.

Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/1942602X10397053

Canham, D.L., Bauer, L., Concepcion, M., Luong, J., Peters, J., & Wilde, C. (2007). An audit of

medication administration: A glimpse into school health offices. Journal of School

Nursing, 23(1), 21-27.

Clay, D., Farris, K., McCarthy, A.M., Kelly, M.W., & Howarth, R. (2008). Family perceptions

of medication administration at school: Error risk factors and consequences. The Journal

of School Nursing 24(2), 95-102.

Collins Dictionary of Law. (2006). in loco parentis. Retrieved from http://legal-

dictionary.thefreedictionary.com/in+loco+parentis

Farris, K.B., McCarthy, A.M., Kelly, M.W., & Gross, J.N. (2003). Issues of medication

administration and control in Iowa schools. Journal of School Health, 73(9), 331 – 337.

Ficca, M., & Welk, D. (2006). Medication administration practices in Pennsylvania schools. The

Journal of School Nursing, 22(3), 148 – 155.

35

Gordon, S.C., & Barry, C.D. (2009). Delegation guided by school nursing values:

Comprehensive knowledge, trust and empowerment. Journal of School Nursing, 25(5),

352 – 360.

Gould Academy. (2017). Mission. Retrieved from https://gouldacademy.org/about/mission/

Gursky, B.S., & Ryser, B.J. (2007). A training program for unlicensed assistive personnel. The

Journal of School Nursing, 23(2) 92-97.

Institute of Medicine (IOM). (2007). Preventing medication errors. Washington, DC: The

National Academies Press. https://doi.org/10.17226/11623.

Kelly, M.K., McCarthy, A.M., & Mordhorst, M.J. (2003). School nurses’ experiences with

medication administration. Journal of School Nursing,19(5), 281 – 287.

Knowles, M. S. (1980). The modern practice of adult education: From pedagogy to andragogy.

Wilton, Conn.: Association Press.

Langan-Fox, J. & Tan, P. (1997). Images of a culture in transition: Personal constructs of

organizational stability and change. Journal of Occupational and Organizational

Psychology, 70, 273-293.

Lavin, R.P., Slepski, L. & Kasper, C.E. (2007). Subject matter experts: Facts or Fiction? Nursing

Forum, 42(4), 189-195.

Litarowsky, J.A., Murphy, S.O., & Canham, D.L. (2004). Evaluation of an anaphylaxis training

program for unlicensed assistive personnel. Journal of School Nursing, 20(5), 279-284.

McCarthy, A.M., Kelly, M.W., & Reed, D. (2000). Medication administration practices of

school nurses. Journal of School Health, 70(9), 371-376.

Maine Department of Education (2005). School Health Advisory Committee: Guidelines

Training non-licensed school personnel in medication administration, instructor’s

36

manual. Retrieved from

http://maine.gov/education/sh/medadmininschools/instructormanual.pdf

National Association of School Nurses (NASN). (2014). Nursing delegation to unlicensed

assistive personnel in the school setting: Position statement. National Association of

School Nurses. Retrieved from

http://www.nasn.org/portals/0/positions/2014psdelegation.pdf

National Association of School Nurses (NASN). (2016). Framework for the 21st century school

nurse practice. Retrieved from https://www.nasn.org/Framework

National Association of School Nurses (NASN). (2017). Position statement: Medication

administration in the school setting. Retrieved from

https://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStateme

ntsFullView/tabid/462/ArticleId/86/Medication-Administration-in-the-School-Setting-

Amended-January-2012

Nibert, M. (nd). 2.5.1 Boyer´s Model of Scholarship. Available at

http://www.facultyguidebook.com/test/2_5_1.htm

Price, J.A., Dake, J.A., Murnan, J., & Telljohann, S.K. (2003). Elementary school secretaries’

experiences and perceptions of administering prescription medication. Journal of School

Health, 73(10), 373-379.

Richmond, S.L. (2011). Medication error prevention in the school setting: A closer look. NASN

School Nurse, 26(5), 304-308.

Robert Wood Johnson Foundation. (2010). Unlocking the potential of school nursing: keeping

children healthy, in school, and ready to learn. Charting Nursing’s Future. Princeton, NJ:

37

Robert Wood Johnson Foundation; 2010;14:1–8. Available at:

www.rwjf.org/content/dam/farm/reports/issue_briefs/2010/rwjf64263.

Schein, E.H. (1990). Organizational culture. American Psychologist, 45(2), 109 – 119.

State of Maine, Department of Education. (2015). School health manual: Introduction. Retrieved

from http://www.maine.gov/education/sh/introduction.pdf

State of Maine, Department of Education. (2017). School health manual: Medication

administration in schools. Retrieved from

http://maine.gov/education/sh/medadmininschools/adminmedsschools.pdf

SurveyMonkeyTM. (2017). Home. Retrieved from https://www.surveymonkey.com

Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach’s alpha. International Journal of

Medical Education, 2, 53–55. http://doi.org/10.5116/ijme.4dfb.8dfd

Thompson, C. (2011). Systematic review evidence table format. In J. Houser & K. S. Oman

(Eds.), Evidence-based practice: An implementation guide for healthcare organizations

(p. 155). Sudbury, MA: Jones and Bartlett.

US Department of Health and Human Services, Office for Human Research Protections. (2017).

Human subject regulations decision tree. Retrieved from

https://www.hhs.gov/ohrp/regulations-and-policy/decision-charts/index.html

Wilt, L., & Foley, M. (2011). Delegation of glucagon in the school setting: A comparison of state

legislation. Journal of School Nursing, 27(3), 185-196.

Zaccagnini, M. E. & White, K. W. (Eds.). (2017). The Doctor of Nursing Practice Essentials: A

model for advanced practice nursing. (3rd Ed.) Sudbury, MA: Jones & Bartlett Learning.

38

Appendix A Systematic Review Evidence Table Format [adapted with permission from Thompson, C. (2011). Evidence table format for a systematic review. In J. Houser & K. S. Oman (Eds.), Evidence-based practice: An implementation guide for healthcare organizations (p. 155). Sudbury, MA: Jones and Bartlett.] 1. Article/Journal Medication administration practices of school nurses.

Journal of School Health, 70(9), 371 – 376. Author/Year McCarthy, A.M., Kelly, M.W., & Reed, D.

2000 Database/Keywords CINAHL

School nurse, medication administration Research Design Survey of nurses Level of Evidence Level VI

Seven Tiered level of evidence, Melnyk, B. M., & Fineout-Overholt, E. (2005).

Study Aim/Purpose Assess, “the current practices of school nurses giving medications in schools” p. 371

Population/Sample size Criteria/Power

Random sample of 1000 school nurses, members of the NASN (out of an estimated 40,000 school nurses at the time of the study) Usable number of surveys returned was 649

Methods/Study Appraisal Synthesis Methods

A confidential survey

Study tool/instrument validity/reliability

Survey was developed thru author experience and expert review, literature review and guidelines, pilot trial used, primarily closed–ended questions

Primary Outcome Measures/Results

High rate of med errors, confusion among nurses on delegation to UAP and nurse practice law *use of UAP showed a significant relationship with med errors, 3.1 times more likely to have a med error p. 374

Conclusions/Implications Need for further research Need for national guidelines “Problems exist with administration of medications to children in schools” p. 376 Level of errors are not acceptable, safety concerns of current practices

Strengths/Limitations Strengths: Large sample size Representatives from all but one state responded Limitations:

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Possibly skewed data due to nurses being part of a professional organization and thus more likely to be cognizant of issues (“school nurses that are NASN members may be more likely to develop medication guidelines” than school nurses that are not members” p. 376) Survey relied on memory and estimates The survey only looked at nurses so is not an accurate sample of how school districts who do not have nurses admin meds

Funding Source None noted Comments 2000 – 17 years old

76% of respondents use UAP to administer medications, with 77% of those receiving in-service education 49% report a med error in the last school year, missed doses was the most common Procedures for dispensing non prescription meds are less defined, possible conflict with States Nurse Practice Acts Concerns noted in storage of refrigerated medications in non locked containers, transferring of meds to non original containers Many nurses noted confusion of if they are even permitted to delegate med admin UAP per their State Nurse Practice Act. Question raised – med errors, in schools with BSN/MSN errors are reported more frequently but is this an effect of a more professional attention to the issue? Possible practice changes to improve safety, ie network with pharmacy for storage solutions

2. Article/Journal An audit of medication administration: A glimpse into

school health offices Journal of School Nursing, 23(1), 21-27.

Author/Year Canham, D.L., Bauer, L., Concepcion, M., Luong, J., Peters, J., & Wilde, C. 2007

Database/Keywords MEDLINE School nurse, medication administration

Research Design Retrospective review of medical records Level of Evidence Level VI


Study Aim/Purpose Evaluate the med admin process at multiple school sites, looking at safe and accurate med admin, management, & documentation.


8 public school sites in Northern California, 154 medications, all elementary schools

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All UAP are trained in CPR and First Aid and receive annual training on medication admin from nsg staff


A medication audit form was created, data was taken from the medical record (logs, records, authorization forms, prescription labels) then compared for transcription accuracy, timing accuracy, total times given accuracy


Use of medication audit form


Med errors were found in all of the study’s categories, total depended on school. Other issues were also discovered such as storage of medications, not notifying school nurse as per policy, meds without permission to give, oral dosing not measured properly, multiple expired medications. Out of 154 meds prescribed, 22 transcribed incorrectly

Conclusions/Implications Continuous eval process & occasional review needed, UAP needs yearly refresher training, nurse must stay on top of medications in the school setting. The audit tool can point to problems and guide further training Results demonstrate multiple med errors, similar to McCarthy, Kelly & Reed, 2000 It is school nurses responsibility to make sure UAPs are trained and understand safety measures p. 27. Nurse must assess logs and UAPs periodically through the year and not just at annual training. Guidelines should clearly state: Who is responsible for med admin Who can the tasks be delegated to How meds should be stored How the process should be documented Amount of training UAPs need How to recognize and handle med errors Plans for meds on sports trips/field trips Self administration

Strengths/Limitations Strengths: statistically significant data, new, unexpected discoveries Limitations: small sample size, geographically limited. In relevance to clinical problem this was not a boarding school

Funding Source Student project in the Clinical Nurse Specialist in School Nursing class at San Jose State University

Comments UAP often feel uncomfortable with the giving of medications.

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Strong support for practice problem focused on UAP med administration “The consistency of findings in this and other previous studies supports the importance of identifying strategies to increase the accuracy of medication administration in the school setting” p. 27 Literature review noted 10 studies in last 10 years, “A common theme in all 10 studies was the medication administration in school was problematic” p. 22 “School nurses are the only school personal with the health care knowledge and they are often are left to interpret and implement medication administration policies” p. 23 UAP training was 5 rights of safe med admin, student, drug, dose, time, route s well as discussion of medication side effects appropriate documentation and storage of medications. P. 23 “Delegating medication administration to UAP is a consistent practice throughout the United States” p. 26 Use of UAPs in administering medication in school is a, “safety issue that can potentially lead to litigation” p.27

3. Article/Journal Evaluation of an anaphylaxis training program for

unlicensed assistive personal Journal of School Nursing, 20(5), 279-284.

Author/Year Litarowsky, J.A., Murphy, S.O., & Canham, D.L. 2004

Database/Keywords MEDLINE Unlicensed assistive personnel, school

Research Design An educational intervention was designed with 53 participants, with measures before and after the intervention

Level of Evidence Level VI Seven Tiered level of evidence, Melnyk, B. M., & Fineout-Overholt, E. (2005).

Study Aim/Purpose “The purpose of this research was to measure the effectiveness of a theory-based anaphylaxis recognition and epinephrine auto-injector training program created for UAPs in the high school setting.” p. 279

Population/Sample size 53 UAP from seven high schools in California urban area

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Criteria/Power Methods/Study Appraisal Synthesis Methods

Training and education with knowledge and “perceived self-efficacy” measured pre/post intervention (anaphylactic emergency)


Pre/post test was reviewed by 6 school nurses


“Significant improvement” pre vs. post intervention

“Theory-based training programs can be effective in addressing both knowledge and self-efficacy.”

Supports a project based on educational interventions for UAPs

Conclusions/Implications Further study using this model and theory on other health based knowledge and UAPs may be useful, esp measurement of confident of UAPs after training.

Strengths/Limitations Limitations: No control group, instruments of data collection were revised, generalization based on small sample size, time constraints restricted long term evaluation Study dated 2004, 12 years ago

Funding Source Not noted, all from same school district. However, “The videotape and EpiPen training devices used in the training program for this study were provided by Dey, Inc., in Napa, California”

Comments Though not the same as a routine med admin, the plan of a teaching intervention and safe med delivery parallels well with project. Unexpected benefit allowing the school nurse to interact with a wide variety of staff

4. Article/Journal Family perceptions of medication administration at

school: Error risk factors and consequences The Journal of School Nursing 24(2), 95-102.

Author/Year Clay, D., Farris, K., McCarthy, A.M., Kelly, M.W., & Howarth, R. 2008

Database/Keywords CINAHL Medication administration, school

Research Design Interview survey

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Study Aim/Purpose “This study examined medication administration from the child and parent perspectives to (a) determine problems children experience with medicines at school, (b) clarify risk factors for medication errors, and (c) examine the perceived impact of medication errors on school performance and social relationships” p. 97


Children 8 - 18 years being treated at a large Midwestern Children’s Hospital in diabetes, asthma, and Attention Deficit Hyperactivity Disorder (ADHD) clinics. Included 75 parents– child dyads with diabetes, 37 with ADHD, and 45 with asthma.


Survey and interview


Semi structured interview, developed based on the clinical and research expertise of the study authors, review of recommended guidelines and the survey was a previously used from McCarthy et all 2000.

Survey was piloted


50% of children taking ADHD med reported problems 25% of children with asthma and 15.3% of children with diabetes.

28% of kids reported med errors at school. Most common error was missed dose

“Medication non adherence at school, which includes medication administration errors such as missing a dose, may potentially lead to a variety of educational, social/emotional, and physical consequences. These results indicate that the impact of missing medication on children with ADHD appeared to have a greater effect on schoolwork and friendships, while the physical consequences appeared to vary widely based on health condition.”

Conclusions/Implications Future research should examine these trends across multiple medical centers.

Reinforces need for education for school personal. “Indicate an ongoing need for school nurses to participate in

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supervising medication administration.”

Strengths/Limitations Limitations: self reported, all participants from the same treatment center, less generalizable

Funding Source “Supported by a grant from the Obermann Center for Advanced Studies Spelman Rockefeller Grant, The University of Iowa, Iowa City, IA.”

Comments 28% of students reported an error in taking their med, suggestion was that when students shared the responsibility for medication administration there were less errors. Agreement with the theme that medication administration in the school setting is problematic. Meds require “systematic collaboration” p. 101

5. Article/Journal A Training Program for Unlicensed Assistive Personnel

The Journal of School Nursing, 23(2) 92-97. Author/Year Gursky, B.S., & Ryser, B.J.


Unlicensed Assistive Personnel, school Research Design Case study Level of Evidence Level VI


Study Aim/Purpose To describe, “how one school district developed and implements a training program for UAP using its school nursing staff”


One school district in Florida 135 completed


A planning committee was formed and designed an 80-hour workshop (10 day course with 33 topics) on health issues in the schools, taught by the school nurses and school NPs. Program developed by the Health Science and Public Education adult program of the school district. Updated every 2 years by nurses doing evidence review.


Planning committee development


A “positive” impact on the school district as they “now better understand the delegation process and have a renewed appreciation for the importance of registered nurses in maintaining excellent health care delivery to students” p. 95

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Conclusions/Implications Due to the course the school district now has a trained UAP in each school

Strengths/Limitations Not a formal study, evaluations are solicited by the staff, not noted in article.

Funding Source School district Comments Supervision and monitoring are 2 essential components in

delegation “While there are many tasks and procedures delegated in schools, medication administration is one of the most common”. P. 93 Suggest that evaluation of med error pre and post intervention is a good measure of effectiveness of training program.

6. Article/Journal Delegation guided by school nursing values: Comprehensive

knowledge, trust and empowerment. Journal of School Nursing, 25(5), 352 – 360.

Author/Year Gordon, S.C., & Barry, C.D. 2009

Database/Keywords MEDLINE Unlicensed assistive personnel, school

Research Design Using the community nursing practice model Qualitative descriptive design and inquiry group method were used, p. 357


Study Aim/Purpose “Explore the values guiding the delegation of nursing task to UAP in school setting from the perspective of the school nurse”. P. 356


School nurses at the annual meeting of FASN (Florida Association of School Nurses), group sessions, 64 nurse with diverse backgrounds


Group sessions approx. 1-1.5 hours, recorded and complied with data categories


Qualitative, but can be reproduced, as questions to begin discussion were standard with groups


Data categories identified Comprehensive knowledge Trust Empowerment

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Conclusions/Implications “Delegation in this study was described as a knowledge process of building and sustaining trusting connections among students, school nurses and UAPs” p. 359 “Empowerment together with the values of trust and comprehensive knowledge provide a framework for a deeper understanding of the delegation process.” p. 359 “The values represented in this study support the recognition of UAP as stakeholders in the care of students in school settings and suggest interventions that support and sustain trusting relationships between the school nurse and UAP are needed. Interventions may include moving from a rule-based to a value-based orientation in the development of education programs designed to enhance school nurse delegation knowledge and skills.” P. 359 Suggestion that use of delegation decision grids, and clear definitions are useful interventions P. 359

Strengths/Limitations Limitations - Small sample size, geographically limited Strengths - Limited other qualitative studies noted, reproducible

Funding Source Florida School Nurse Research Initiative Comments Noted discussion on the remoteness of nurse delegation in

school nursing (as opposed to in an acute care facility) creating a unique issue. P. 354 Discussion – school nurses “across the country share concerns regarding the impact of delegating medication administration to UAP on the health and safety of school age students” p. 355 Most studies have been quantitative but they note more qualitative studies are needed p. 355 Five Rights of Delegation (NCSBN 1995) 1. Task, 2. Circumstance, 3.person delegating, 4. Directions or communications, 5. Circumstances p. 353

7. Article/Journal Delegation of Glucagon in the school setting: A comparison

of State Legislation. Journal of School Nursing, 27(3), 185-196.

Author/Year Wilt, L., & Foley, M. 2011

Database/Keywords MEDLINE Unlicensed assistive personnel, medication administration

Research Design Review of literature and exploration of existing data

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Study Aim/Purpose Exploration of glucagon delegation laws in the US Population/Sample size Criteria/Power

Existing literature, not defined


Literature review


N/A


Literature review common themes noted: legal concerns, comfort levels of the delegating nurses and UAP and med errors

Conclusions/Implications “It is clear from the literature that school nurse experience difficulty deciphering the laws under which they practice” p. 193 Noted that those that make laws pertaining to delegation often have no nursing experience and nurse should be involved as consultants p. 193 “In addition, if a school nurse makes a nursing judgment that a particular delegate would not be an appropriate person to administer emergency medication that decision must be respected and upheld.” P. 193 “Adequate and appropriate training of UAP in the school setting will assist school nurses to ensure student safety and meet the challenges of caring for students in an emergency situation”. P 193

Strengths/Limitations Further research – care of the student with diabetes in the school setting, school nurses experience with glucagon delegation, frequency of delegation, and examining outcomes after delegation.

Funding Source None noted Comments “The delegation of procedures and treatments may be used only

in compliance with individual state nurse practice acts, state regulations and guidelines.” P. 186 “Legal authority for delegation of medication administration by school nurses comes from individual NPAs as well as educational law.” P 188 Maine is noted to have ability to delegate glucagon administration to UAP p. 189

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Administrators “believe they are ultimately responsible for anything occurring in the school and nurses understand that by state law, nurses are ultimately responsible for medication administration”. P 188

8. Article/Journal Elementary school secretaries’ experiences and perceptions

of administering prescription medication. Journal of School Health, 73(10), 373-379.

Author/Year Price, J.A., Dake, J.A., Murnan, J., & Telljohann, S.K. 2003

Database/Keywords MEDLINE Medication administration, school

Research Design Survey directed to secretaries at elementary schools, randomized Level of Evidence Level IV


Study Aim/Purpose Assessed a national, random sample of elementary school secretaries regarding their experiences and perceptions with prescription medication. “The survey offers further insight regarding whether such delegation compromises health care received by elementary school children.” P. 373


600 randomly selected Elementary schools in the US, survey was sent to the school secretary.


3 wave mailing procedure. Returned surveys were analyzed Statistical analysis


A literature review was used to validate the questions, then reviewed by 5 qualified school health nurses, final instrument contained 31 items, 21 assessing perceptions and practices of the school secretaries on distributing medications. Piloted first


26% had received NO training in med administration, those with more training felt more prepared to administer meds, 28% received less than one hour of training 85% reported no medication errors in the past year (nurses reported 48% med error, possible not recognizing errors)

Conclusions/Implications School districts should hire adequate numbers of school nurses to meet medication needs Polices on med admin need to be regularly reviewed School nurse who delegate need to understand risk of liability.

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UAP needs to advocate for adequate training. Strengths/Limitations Limitations – strong response rate, but would non-respondents

report differently? Secretaries may have responded to some questions in a “socially desirable manner” Closed format structure of questions.

Funding Source Not disclosed Comments Those most commonly delegated to are often the ones with the

least formal education (secretaries) Overall secretaries disliked administering medications. Noted that errors were inconsistently reported, perhaps due to the UAP not knowing that there was an error.

9. Article/Journal Medication error prevention in the school setting: A closer

look. NASN School Nurse, 26(5), 304-308.

Author/Year Richmond, S.L. 2011


Research Design N/A Level of Evidence Level VI


Study Aim/Purpose Review of common mediation errors that occur in a school setting, prevention strategies


N/A


N/A


N/A


Missed dosing is most common error reported. Use of UAP and high volume noted to be contributing factors in errors.

Conclusions/Implications “A first step in reducing errors involves building a non punitive environment where there is a culture shift toward learning from errors, minimizing an averting future errors, and supporting nurses who have experienced error as a result of process or system failure.” P. 305

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One potential way to learn from medication error and prevent future errors is to establish a medication error reporting system specific to the school environment.” P. 305 Advocating for a common language of error reporting in schools Call for use of technology to mitigate potential medication errors.

Strengths/Limitations Review only Funding Source Not disclosed Comments “The standards of professional performance developed by the

National Association of School Nurses identifies the need for school nurses to enhance the quality and effectiveness of their practice. Improving the safety of medication administration and preventing medication errors are examples of how nurses can demonstrate meeting this standard.” P. 304 Effects of medication errors are difficult to assess in the school setting due to lack of study and limited data collection.

10. Article/Journal Issues of medication administration and control in Iowa

schools. Journal of School Health, 73(9), 331 – 337.

Author/Year Farris, K.B., McCarthy, A.M., Kelly, M.W., & Gross, J.N. 2003


Research Design Descriptive, self administered survey, mailed to Level of Evidence Level IV


Study Aim/Purpose To describe who is responsible for medication administration in Iowa schools, policies in place and med errors


850 principles in schools in Iowa, randomized, 396 useable surveys returned


Freq distribution and descriptive statistics used to evaluate the data


Adapted from previous survey of nurses on med admin, anonymous


Medication errors Rx transportation Legal and liability responsibly is murky

Conclusions/Implications Nurses and administration need to know the nurse codes of their states to determine legal and liability issues. Need for

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written policies for field trips are necessary. Need for strategies to improve communication between school and parents. Potential diversion of prescription medication requires further study.

Strengths/Limitations Limitations: Non-respondent analysis unavailable, response rate was acceptable but stilling limiting. Suspected under reporting of med errors

Funding Source Note reported Comments Principals believed they were legal ultimately responsible

but nurses stated they were in accordance with the Nurse Practice act. P. 335

11. Article/Journal School nurses’ experiences with medication administration.

Journal of School Nursing,19(5), 281 – 287. Author/Year Kelly, M.K., McCarthy, A.M., & Mordhorst, M.J.


School, medication administration Research Design Survey then focus group Level of Evidence Level IV


Study Aim/Purpose To describe school nurses medication administration experiences.


Random sample of 100 members of the NASN, 649 completed then competed focus group of 25 local nurses


Qualitative analysis of a written survey and focus groups Comments on the 8 items from a previous study were analyzed then to clarify information obtained, 2 focus groups of school nurse were conducted


Survey tool was developed based on information from school nurses about procedures, practices and concerns related to med admin, review of recommended guidelines, experience of investigators and critique of survey by expert consultant. Pilot trial of 25 local school nurse.


Nurses across the country have similar medication administration issues. Professional unease and potential for medication errors.

Conclusions/Implications “Clear guidelines for the delegation of medication administration combined with a standardized education system for UAP’s would be an important step in addressing the nurses concern”. P. 285 “The issue of delegation warrants further study, however a minimum requirement is that all school nurses know their

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state nurse practice act and the laws governing the delegation of medication administration.” Written guidelines are essential

Strengths/Limitations Not noted Funding Source Glaxo Wellcome/Midwest Nursing Research Society

Research Grant Comments Significant variation in delegation of med admin

Significant variation in comfort level with delegation Self admins was prevalent Variety of medication errors reported, most common was missed doses. UAPs with inadequate training was also concern, “delegation of medication administration to UAPs raises questions of liability, accuracy and confidentially for the nurses”. P. 285

12. Article/Journal Medication administration practices in Pennsylvania

schools. The Journal of School Nursing, 22(3), 148 – 155.

Author/Year Ficca, M., & Welk, D. 2006

Database/Keywords MEDLINE School, medication administration

Research Design Written survey Level of Evidence Level IV


Study Aim/Purpose Was to determine the policies and practices that PA public schools have in place regarding med admin.


314 state certified school nurses (45% return rate)


Survey analysis


71 question survey, modified from the Mediation Administration in the school setting with content validity established.


School nurses are very concerned about issues related to medication administration. Lack of standing orders for OTCs, increase in med admin when the school nurse had

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multiple responsibilities and lack of understand of the state nurse practice act.

Conclusions/Implications Recommendations for practice include the development of detailed policies and procedures and collaboration among all stakeholders in the development of policies that addressed legal issues.

Strengths/Limitations Limitations: self reported and not verified Funding Source None noted Comments 70% of nurse report they do not give all medications, many

report unease with delegation Med admin on field trips were a concern.

13. Article/Journal Does school nursing matter? NASN School Nurse, March,

72-74. Author/Year Bergren, M.D.

2011 Database/Keywords MEDLINE

School, medication Research Design n/a – Topic discusion Level of Evidence Level IV


Study Aim/Purpose n/a Population/Sample size Criteria/Power

n/a


n/a


n/a


n/a

Conclusions/Implications A call to identify school nursing sensitive out comes to reflect practice

Strengths/Limitations Discussion only Funding Source None noted Comments “One of NASN’s research priorities is to identify school

nurse delivery models (school nurse caseloads, credentials, experience, etc.) that are necessary to deliver quality nursing care in school to children (NASN, 2010a). In order to do that, the school nursing subspecialty must identify what outcomes can be expected as a result of quality school nursing care.” P. 72

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Appendix B

IRB Approval

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APPENDIX C

Copy of Letter of Approval from Organization

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Appendix D

Participant Information Sheet

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Appendix E

Data Dictionary, Survey Questions & Coding

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Field Data Type Coding Exact Question on Survey Pre Survey

Question 1 Code Word

Word/number N/A Please create a code word. You will be asked to enter this again in the post training survey.

Pre Survey Demographics

Pre Survey Question 2 Position

Word

Faculty = 10 Coaching = 11 Other Staff = 12

What is your primary position at the facility? Faculty Coaching Other staff

Pre Survey Question 3 Years giving meds in any school

Number Number How many school years have you administered medications in ANY school environment, here or other school? You may enter, "0" if you have never administered medications in school

Pre Survey Question 4 Years giving meds in this school

Number Number How many school years have you administered medications at this school? You may enter, "0" if you have never administered medications at this school

Pre Survey Question 5 Training received

Word

Yes = 2 No = 1 I don’t remember = 3

Have you ever received training at this school to administer medications?

Pre Survey Respondent

Pre Survey Question 6 Responsibility

Word

Yes = 2 No = 1 Unsure = 3

Do you believe that medication administration is part of your job?

Pre Survey Question 7 Preparation

Number 1-10

1 = strongly disagree 5 = neutral 10 = strongly agree Respondent can select any number from 1 – 10

Right now, I feel prepared to administer medications to students.

Pre Survey Question 8 Confidence level

Number 1-10


Right now, I feel confident in administering medications to students.

Pre Survey Question 9 Med error

Word Yes = 2 No = 1 Unsure = 3 I have never given meds = 4

If you have given medications in a school setting before, have you ever made a medication error?

Pre Survey Knowledge

Pre Survey question 10 - 19

Multiple choice A, B, C, or D

Correct = 21 Incorrect = 20 Blank = 20

Questions based on content

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True/false Fill in the blank

Post Survey

Question 1 Code Word

Word/number N/A Please enter the code word you created in the Pre Training Survey.

Post Survey Respondent

Post Survey Question 2 Preparation

Number 1-10


Right now, I feel prepared to administer medications to students.

Post Survey Question 3 Confidence level

Number 1-10


Right now, I feel confident in administering medications to students.

Post Survey Question 4 Med error

Word Yes = 2 No = 1 Unsure = 3 I have never given meds = 4

After completing the training, do you think you have you ever made a medication error?

Post Survey Knowledge

Post Survey question 5 - 14

Multiple choice A, B, C, or D True/false Fill in the blank

Correct = 21 Incorrect = 20 Blank = 20

Questions based on content

Appendix F

Samples Statistics

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Appendix G

One Way ANOVA Questions 2, 3, 4 and 5

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Question 3

Question 4

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Question 5

63

Question 6

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Appendix H

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Wilcoxon Signed Ranks Tests

Question 7 Wilcoxon Signed Ranks Preparedness

Question 8 Wilcoxon Signed Ranks Confidence

Wilcoxon Signed Ranks Test for Questions 7 & 8

Appendix I

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